Effect of Nursing Intervention on Nurses' Performance regarding the Prevention of Deep Vein Thrombosis among Postpartum Women

Background: Deep veins thrombosis (DVT) is a common obstetric problem associated with greatest risk of developing pulmonary embolism. Only through early identification of risky women, diagnosis and treatment the morbidity can be reduced. The aim of this study was to determine the effect of nursing intervention on nurses' performance regarding the prevention of deep vein thrombosis among postpartum women. Subjects and Method: A quasi-experimental research design was used to conduct this study on 100 nurses who were working in the postpartum units at 8 central and general hospitals in El Gharbia governorate, Egypt. Two tools were used for data collection, Tool I: Assessment of Nurses' knowledge regarding the Prevention of Postpartum Deep Vein Thrombosis Structured Questionnaire and Tool II: Assessment of Nurses' Practices regarding the Prevention of Postpartum Deep Vein Thrombosis Observational Checklist . Results: there was a highly statistically significant improvement in the total knowledge and practices scores of the participant nurses regarding the prevention of postpartum DVT after provision of the nursing intervention (P=0.0001). Conclusion: nurses' knowledge and practices regarding the prevention of deep vein thrombosis among postpartum women was enhanced after the implementation of the nursing intervention. Recommendation: Further constant learning plans and in-service training programs about DVT preventive measures are necessary for nursing staff to participate actively in early detection and prevention of DVT among postpartum women.


Introduction
Venous thromboembolism (VTE) is a major health concern during the postpartum period.While the risk of VTE is fivefold during pregnancy, this risk is increased to 60-fold during the postpartum period (1)(2)(3).It is considered one of the leading causes of maternal morbidity and mortality, accounting for 10-30% of all maternal deaths in the United States and other Western countries (2,4).But in Egypt, the precise prevalence of VTE among the general Egyptian population isn't reported.Venous thromboembolism is classified as deep vein thrombosis (DVT) and pulmonary embolism (PE) (5).Deep vein thrombosis (DVT) refers to an obstruction of deep veins of the calf, thigh, or pelvis by thrombus associated with inflammation of the vein.The three primary reasons for developing thrombosis during pregnancy and postpartum period include; venous stasis due to pressure of the pregnant uterus on lower extremity vein, endothelial injury during childbirth particularly during forceps-assisted delivery or cesarean surgery, and hypercoagulability caused by hemostatic system (6,7) .Moreover, there are many different factors that further increase the postpartum women's risk for DVT.These factors include; thrombophilia, hypertension, personal or family history of venous thromboembolism, obesity, smoking, over age older than 35 years, severe varicose veins, immobility for over 3 days, previous DVT and dehydration.In addition to, the obstetrical risk factors which include; multiparity, prolonged labor, still birth, eclampsia, postpartum hemorrhage or infection (8- 13) .
Deep vein thrombosis is manifested by the following signs and symptoms; edema, warmth, redness and calf pain or tenderness in the affected leg or positive Homan's sign.While in extreme cases, the leg may appear visibly pale or white with diminished pedal pulses.Diagnosis of deep vein thrombosis requires a lot of accuracy.The evidence-based method of diagnosing DVT is the comprehension evaluation of disease risk factors, as well as signs & symptoms.Deep vein thrombosis is a serious and lifethreatening condition that can be fatal if not treated (14)(15)(16).The primary goals of DVT treatment are to prevent further thrombus formation or develop pulmonary embolism (PE).Anticoagulant therapy is the treatment of choice.However, if the condition isn't diagnosed early and treated properly many complications may arise.Approximately 50% of DVT may lead to silent PE.Besides, post thrombotic syndrome that is a frequent disabling long term complication of DVT.In recent years, the prevention of postpartum DVT has been identified nationally and internationally as a priority area for improving patient safety (17)(18)(19) .The best standard practices for prevention of DVT are; comprehensive assessment of high risk factors for DVT, starting active and passive range of motion exercise for the lower extremities, early ambulation, leg or foot exercise, elevation of lower extremities, adequate hydration, administering prescribed prophylactic anticoagulant and using mechanical prophylaxis such as graduated compression elastic stocking and intermittent compression devices as compression boots (20)(21)(22)(23) .Based on Egypt's Vision 2030 for improving the quality and safety of health services provided in the new republic, the General Authority for Healthcare Accreditation & Regulation developed a clinical standard for the prevention of DVT through examining the patients' risk of developing venous thromboembolism (DVT& PE), reevaluating them periodically, and dealing with them in a safe and effective manner (NSR 1): ICD.13) (24).Nurses are considered always the frontlines in delivering the therapeutic regimens of both prevention and treatment of DVT.They can play a major role in the prevention of postpartum DVT, if well-educated and empowered to increase their level of knowledge and practice (25).

Significance of the study:
Deep vein thrombosis is a serious medical condition in the postpartum period with potentially life-threatening complications.It is considered the third most common cardiovascular condition following myocardial infarction and stroke.Although DVT is Vol.31.No. 4 (Suppl 1) ,November 2023 a major medical problem, it is a treatable and even a preventable disease.However, the prevention of DVT isn't possible as it is needed and expected despite the advance in medical care, the presence of standard guidelines, and effective strategies (6,26) .Many researches in Western and Middle Eastern countries has identified several barriers inhibiting nurses' utilization of DVT preventive measures, including lack of nurse compliance, time, confidence to apply DVT prophylaxis, as well as knowledge deficits, under recognition of DVT signs, inadequate DVT assessment, and misperception of DVT prophylaxis underutilization (21,(27)(28) .Moreover, nurses may feel a diminished sense of responsibility to carry out a DVT risk assessment and lack standardized tools or protocols for DVT prevention (5) .So, this study was aimed to determine the effect of nursing intervention on nurses' performance regarding the prevention of deep vein thrombosis among postpartum women.

The aim of the study
The aim of this study was to: -Determine the effect of nursing intervention on nurses' performance regarding the prevention of deep vein thrombosis among postpartum women.

Research hypothesis:
-Nurses' knowledge regarding the prevention of postpartum deep vein thrombosis expected to be enhanced after implementing the nursing intervention.-Nurses' practices regarding the prevention of postpartum deep vein thrombosis expected to be enhanced after implementing the nursing intervention.

Subjects and Method Subjects I) Research Design:
A quasiexperimental research design was used to fulfill this study (one group, pre/ post-test design).

II) Setting:
The study was carried out in the postpartum units of eight central &general hospitals at El-Gharbia governorate.The governorate encompasses 8 administrative centers including Tanta center, Basyoun Center, Qotour Center, El Santah Center, El Mahalla El Kubra Center, Samannoud Center, Kafr El-Zayat Center& Zifta Center.Each center has main central or general hospital equipped to provide services during pregnancy, labor, and postpartum periods for women who are living in the center and its villages.Selection of these hospitals was based on the following factors: these hospitals were the main hospital in each center with the presence of postpartum units; these hospitals were affiliated to the Ministry of Health and Population which need more attention from researchers.In addition to the increased flow rate of pregnant women who receive postnatal care in these hospitals.This increased the susceptibility for the direct contact of studied nurses to postpartum women.These hospitals were as follows: -El-Menshawy General Hospital (Tanta center).
-Zefta General Hospital (Zefta Center).It was developed by the researchers in Arabic language after reviewing the recent related literature and previous studies with similar objectives (20)(21)(22)(23)(24)(25)(26)(27)(28) (26), and was adapted by the researchers after reviewing the recent related literatures (24) to assess the nurses' preventive practices regarding postpartum DVT, which consisted of ( 12) statements regarding assessment of risky women, performing Homan's sign test, giving prescribed anticoagulant drugs, preventive practices and patient teaching aspects.

Scoring system:
Each statement regarding the practices was divided into three categorize, score (2) for the items which was done correctly and completely, score (1) for the items that done correctly and incompletely, and score (0) for the items that done incorrectly or not done.The total practice score ranged from 0-24 and categorized as follows: -Unsatisfactory practice: <80% (0-18).

Method
The study was conducted according to the following steps:-1.
Official letter clarifying the purpose of the study was obtained from the Faculty of Nursing, Tanta University and submitted to El Gharbea Nursing Syndicate which in turn sended official letters to the responsible authorities of the selected settings to obtain their approval and cooperation to carry out the study.

2.
Ethical and legal considerations: -Ethical approval was obtained from the Scientific Research Ethical Committee of Faculty of Nursing, Tanta University before starting the study (Ethical Code: 260 -5 -2023).-All nurses were informed about the purpose, nature, and benefits of the study at the beginning of data collection and asked to share in the study willingly.Then informed consent was obtained.-Confidentiality and privacy were taken into consideration regarding the data collection; the nurses were assured that all data will be used only for the research purpose and the participant's rights to withdraw at any time if desired.

Validity & reliability:
-Study tools were tested for content and construct validity by a panel of five experts in the field of obstetrics and gynecological nursing.The face validity of the tools were calculated based on experts' opinion after calculating content validity index (%) of its items and it was 92.8% & 90.9% respectively.While, the study tools were measured for internal reliability using Cronbach's Alpha correlation coefficient.The results proved that tools were reliable with a correlational coefficient 0.875 for Tool I and 0.86 for Tool II. 4. Pilot study: was carried out on 10% of the nurses (10 nurses), from the previously mentioned settings to test the clarity, feasibility and applicability of the developed tools.The pilot study was conducted before the actual data collection.Accordingly, based on the results of this pilot study no necessary modifications were done, then the tools made ready for use.Data obtained from the pilot study were included.5. Data collection was conducted over a period of 4 months from the beginning of June 2023 to the end of September 2023.Data were collected from El-Menshawy General Hospital, followed by Basyoun Central Hospital, then Qotour Central Hospital, El-Santah Central Hospital & Zefta General Hospital, followed by El Mahalla El Kobra General Hospital then Samannoud Central Hospital & Kafr El-Zayat General Hospital.The educational program was conducted firstly at El Gharbia Nursing Syndicate teaching class for both the theoretical and the clinical parts of the program at a rate of 2 group/ week.Then the researchers transferred to the postnatal units in the previously selected hospitals for evaluation in morning and afternoon shifts, until the predetermined sample size was collected.6.  (17,24,33,37) and had been confirmed by experts to enhance nurses' knowledge and practices regarding the prevention of postpartum DVT.It was designed using simple Arabic language and different illustrative pictures to facilitate the nurses understanding of its contents.The aim of this phase was to evaluate the nurses' knowledge and practice about the prevention of postpartum DVT.The researchers met with the studied nurses at the morning and afternoon shifts in postnatal wards of the previously selected hospitals for evaluation.
-Nurses' knowledge regarding postpartum DVT and its prevention was assessed immediately after implementation of the educational program and one month later using Tool (I) part 2& part 3.
-Assessment of nurses' practice regarding the prevention of DVT among postpartum women was done by using Tool II (observational checklist).

Statistical analysis:
The collected data were coded, entered, tabulated and analyzed using SPSS (Statistical Package for Social Science) version 25 (IBM Corporation, Armonk, NY, USA).For quantitative data, the range, mean and standard deviation were calculated.For qualitative data, which describe a categorical set of data by frequency, percentage or proportion of each category, comparison between two groups and more was done using Chisquare test ( 2 ).For comparison between related more than two means of non-parametric data (before, immediate after and one month after implementation of educational guidelines), Friedman Test ( 2 value) was calculated.For comparison between means of two groups of non-parametric data of independent samples, Z value of Mann-whitney test was used.For comparison between more than two means of non-parametric data, Kruskal-Wallis ( 2 value) was calculated.
Correlation between variables was evaluated using Pearson's correlation coefficient (r).

Table (1):
Displays that two fifths of the studied nurses (40.0%) aged more than 40 years old.In relation to the educational level, more than two fifths of the studied nurses (43.0%) had secondary nursing education, while 24.0% had technical institute of nursing and only 5.0% of them had master degree in nursing sciences.It is also estimated that more than two third of the studied nurses (68.0%) were from rural areas, and most of them (87%) were married.Regarding years of experience, slightly more than half of the studied nurses (53.0%) had >20 years of experience.The table also demonstrates that most of the studied nurses (88.0%) didn't have any previous training programs regarding the prevention of deep vein thrombosis (DVT) during postpartum period.Table ( 2 ):Exhibits that there is a highly statistical significant positive improvement in the studied nurses knowledge immediately & one month post the nursing intervention compared to pre-nursing intervention program about nearly all the knowledge items s' regarding deep vein thrombosis as p=0.0001* respectively.Table (3):Illustrates that there is a highly statistical significant positive improvement in the studied nurses' knowledge immediately & one month post the nursing intervention compared to pre-nursing intervention program about all the knowledge items regarding the prevention of postpartum deep vein thrombosis as p=0.0001* respectively.Figure (1): highlighted a highly statistical significant differences in the total score level of knowledge about postpartum DVT and its prevention among the studied nurses before and after implementation of the nursing intervention (p= 0.0001), which is improved from low level of knowledge among 93.0% of the studied nurses before the nursing intervention to high level among (100.0%and 92.0%The aim of study was to determine the effect of nursing intervention on nurses' performance regarding the prevention of deep vein thrombosis among postpartum women.This aim and the hypotheses of the study were achieved through the study results which highlighted significant improvement in the nurses' level of knowledge and practices regarding the prevention of postpartum DVT after nursing intervention.The results of the present study revealed that two fifths of the studied nurses aged more than 40 years old, two thirds of them were from rural areas and most of them were married.Also, more than two fifths of the studied nurses had a diploma of nursing.Even though deep vein thrombosis is a serious medical condition accounting for most cases of pulmonary embolism (31) , the results of the present study clarify that most of the studied nurses didn't have any previous training programme about prevention of postpartum deep vein thrombosis.This is supported by Malk R et al., (2022) (32) (33) who conducted a descriptive cross-sectional study to assess "Nurses' Knowledge and Practices Regarding the Prevention of Deep Vein Thrombosis in Saudi Arabia", they revealed that nearly three quarter of the studied nurses had received previous DVT education.Therefore, in an effort by the Egyptian government to achieve national safety, out of its belief that patient safety is a goal that must be achieved, the General Authority for Healthcare Accreditation & Regulation (GAHAR) affiliated to the Egyptian Ministry of Health and Population in cooperation with Egyptian Society of Surgeons, Egyptian Society of Obstetrics and Gynecology, Egyptian Society for Intensive Care and Trauma, Egyptian Orthopedic Society and Egyptian Society for Vascular Sciences had launched the "No to venous clots" initiative.This initiative aims to train doctors, pharmacists and nurses on the medical protocol for venous thromboembolism in order to develop a methodology for multidisciplinary work to ensure the quality and safety of the initiative's outputs (24) .In relation to the total score level of knowledge regarding postpartum DVT and its prevention among the studied nurses, the results of the present study revealed that most of the studied nurses before the nursing intervention had low level of knowledge.This may be due to the absence of in-service training program, lack of time because of over work load and lack of technology resources to search and upgrade their knowledge.Also, this may Vol. 31.No. 4 (Suppl 1) ,November 2023 be attributed to the low level of education, as more than two fifths of the studied nurses had only nursing diploma and graduated since a long period of time so they might lose too much of their basic graduation knowledge.In accordance, Mohammed WI et al., (2019) (34) (35) who studied the " Nurses' knowledge, attitudes, and behaviors toward venous thromboembolism prophylaxis: How to do better", stated that the overall knowledge level of the studied nurses was not optimistic.Supported by Yohannes S et al., (2022) (36) whose study was to assess "Nurses' Knowledge, Perceived Practice, and their Associated Factors regarding Deep Venous Thrombosis (DVT) Prevention in Amhara Region Comprehensive Specialized Hospitals, Northwest Ethiopia, 2021: A Cross-Sectional Study", founded that Knowledge of the nurses regarding the prevention of deep venous thrombosis was inadequate.While, the total score level of knowledge in the present study was significantly improved to high level among the entire sample immediately after the nursing intervention and among most of them one month later of implementing the intervention, with a highly statistically significant difference regarding knowledge about postpartum DVT and its prevention pre-and postintervention.This may be attributed to the effect of the research intervention.Also, the desire of the studied nurses to know, understand and share experience about this major medical problem that affecting postnatal women and how to do better effort to prevent it because some of them faced postpartum DVT cases but they didn't know how to deal with it.The finding of the current study was in agreement with Malk RN et al., (2022) (32) who reported that the majority of the studied nurses had got statistically significant improvement in their knowledge post the program implementation.This is further stressed by the systematic review on "nurses' knowledge, risk assessment practices, self-efficacy, attitudes, and behaviors towards venous thromboembolism (VTE)" performed by Al Mugheed K H, and Bayraktar N, (2023) (37) who concluded that comprehensive educational programs and campaigns based on well-established and standardized tools should be provided to nurses to improve their VTE knowledge.However, the result of the present study disagreed with Alyousef HA et al., (2022) (33) .Based on the result of their study, most of the studied nurses' level of knowledge concerning the prevention of deep vein thrombosis ranged between high and very high.This may be attributed to the high level of education among their studied nurses where, nearly all of them were a bachelor's degree.Also, most of them had received previous DVT education and the primary source was in-service education and nearly all studied nurses agreed to the Vol.31.No. 4 (Suppl 1) ,November 2023 presence of a protocol in the hospital for DVT prevention.
Concerning the total score level of practices regarding prevention of postpartum DVT among the studied nurses, all of the studied nurses had unsatisfactory practices before implementing the nursing intervention.These unsatisfactory practices may be due to the absence of in-service training programs and refreshing courses regarding preventive measures of DVT during postpartum.Additionally the most important factor from the researchers' point of view, is the absence of clear protocol for prevention of postpartum DVT in the hospital policy.This result was compatible with Oh H et al., (2017) (10) who conducted a crosssectional survey to examine the "Clinical nurses' knowledge and practice of venous thromboembolism risk assessment and prevention in South Korea", demonstrated a low level of VTE practice for registered nurses and they concluded that nurses' low level of self-efficacy in VTE prevention/prophylaxis could be a considerable barrier to optimal VTE prevention.Also, Al Mugheed K H, and Bayraktar N, (2021) (38) who studied "Knowledge and practices of nurses on deep vein thrombosis risks and prophylaxis: A descriptive cross sectional study", stated that nurses had poor practices with respect to the prevention of deep vein thrombosis.Also, on the systematic review conducted by Al Mugheed K H, and Bayraktar N, (2023) (37) they found five studies reported that nurses had poor VTE practice levels.
The current study also revealed that the total practices score was significantly improved among most of the studied nurses immediately after the nursing intervention and among more than four fifth of them one month after implementation of the intervention.This may be due to demonstration and redemonstration as well as role playing throughout the clinical educational sessions.This result agrees with Malk RN et al., (2022) (32) who clarified that nurses' practices improved post program implementation.In contrast, this result is remarkably differ from the results obtained by Zheng E et al., (2017) (39) who studied the "Current Status of Prevention and Nursing on Venous Thromboembolism among Perioperative Patients with Lung Cancer", illustrated that the clinical staff have already realized the importance of VTE prevention.This may be due to more than half of their hospitals had VTE prophylaxis for hospitalized and discharged patients Moreover, the present study results showed a significant positive correlation between total knowledge scores and total practices scores of the studied nurses' pre, immediately and one month postintervention.This is in line with Lau et al., (40) whose study "Effectiveness of two distinct web-based education tools for bedside nurses on medication administration practice for venous thromboembolism prevention: A randomized clinical trial", stated that education for nurses significantly improves practice.Similarly, Kiflie A M et al., (2022) (41) whose study "Assessment of knowledge, attitude, Figure (1): Level of knowledge of the studied nurses about deep vein thrombosis (DVT) among postpartum women and its prevention before and after implementation of the nursing intervention.

Figure ( 2
Figure (2): Total score level of practices of the studied nurses about prevention of deep vein thrombosis (DVT) among postpartum women before and after implementation of the nursing intervention.

Table ( 3): Knowledge of the studied nurses regarding prevention of deep Vein Thrombosis (DVT) before and after implementation of the nursing intervention B-Knowledge items about prevention of Deep Vein Thrombosis (DVT) Response of the studied nurses before and after implementation of the educational guidelines (n=100)
*Statistically significant (P<0.05)Vol. 31.No. 4 (Suppl 1) ,November 2023